Please enter the patient's appropriate EMR related information
Patient needs to be referred to BCS for consultation. They have indicated a Screening Mammogram appointment with a new breast problem.
One of our Breast Center schedulers will contact you to schedule an appointment. Please make sure you provided your best contact phone number in the designated box above.
Please list anyone that we may contact to get or disclose personal information on your behalf.
You may obtain a copy of the University Health Systems (UHS) Notice of Information Practices at any time by clicking here, calling (865) 305-9118, or by requesting one at the UHS or UHSV office. This document describes how your health information maybe used or disclosed by UHS, UHSV Facilities and it should read it carefully. Be aware that this document may be changed at any time.
Our radiologists believe Breast Tomosynthesis/DBT is a valuable tool to provide a definitive diagnosis and reduce patient recalls for additional evaluation. Breast Tomosynthesis produces a three dimensional view of the breast tissue, which helps the radiologists identify and characterize individual breast structures without the confusion of overlapping tissue.
While Breast Tomosynthesis can benefit all screening and diagnostic mammography patients, it is especially valuable for women receiving a baseline screening, those who have dense breast tissue, and women with a personal history of breast cancer.
The Breast Tomosynthesis screening experience is similar to a traditional 2D mammogram. During the exam, multiple low-dose images of the breast are acquired at different angles. These images are then used to produce a 3D image of the breast in a series of one-millimeter slices, enabling the radiologist to scroll through the images to view the layers of the breast.
Our radiologists recommend you have DBT based on your tissue type or family history. Many insurance providers are now reimbursing for DBT, however it is important to understand that in some cases, insurance may not cover these services. You may want to check with your insurance to see if your plan offers coverage for Breast Tomosynthesis/3D mammography.
FOR EXAMPLE: BCBS currently applies the screening Tomosynthesis imaging cost to your annual deductible and will reimburse accordingly if your deductible is met. Please contact BCBS if you have questions regarding this benefit.
All services will be filed with your insurance company and reviewed in the event the service is recognized as investigational by your insurance provider.
If you have any questions, please contact our patient representative @ 865-305-8158.
***DBT- Digital Breast Tomosynthesis, also referred to as 3D imaging or Tomo
Your physician has recommended that you have a mammogram/biopsy. This procedure is currently the best way to detect a change that cannot be felt or to clarify a change that can be felt.
Breast implants require a special type of exam. This is because the implant does obscure breast tissue. Your implant will need to be gently moved out of the way for some of the images. The technologists have been trained to perform this special exam.
As with all mammograms, some compression will be applied. For the images with the implants in view, compression will be applied to prevent motion. In the images with the implant moved back, compression will be applied normally, possibly causing some discomfort – usually lasting only a few seconds.
It is not unusual for a rupture that was not felt by you or your physician to first be noticed on a mammogram. But, like a balloon, an implant that is old or weakened can rupture at any time, even during a mammogram/biopsy. This is a rare occurrence but cannot be ruled out, as the condition of the implant cannot be verified prior to the mammogram.
Since the possibility of a rupture is minimal, and the benefit of mammography/biopsy is well documented, we hope that you will proceed and allow us to perform this special study.
Please complete for all current and prior breast implants. Please enter pertinent information for each set of implants.
Open Capsulotomy: A surgical operation performed to treat and remove scar tissue which occurs around breast implants or to revise the shape of the implant pocket.
Closed Capsulotomy: An in office procedure where the breast is forcefully massaged to soften the capsule that surrounds the implant.
Please contact the scheduling department to reschedule your Dexa scan so that it is more than 2 weeks apart from your barium X-Ray.
Please list the name and location of the healthcare facility where you had your last Mammogram.
With your signed authorization, we will request breast health related records from the healthcare facility that you list below.
You have a right to revoke this authorization by doing so in writing and mailing to the Medical Record Department at the address below.
UT Medical Center, Medical Records Dept, 1924 Alcoa Hwy U-110, Knoxville, TN 37920.
Such revocation will be effective to the extent that action has not been taken in reliance on the authorization or, if the authorization was obtained as a condition of obtaining insurance coverage, only to the extent that other law provides the insurer with the right to contest a claim under the policy.
I understand that this authorization is voluntary and that I may refuse to sign this authorization, and that my refusal will not affect my eligibility for benefits, payment for coverage of services, or ability to obtain treatment.
The information used or disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by the regulations that protect individually identifiable health information from use or disclosure by health care providers.